16 Intent to leave nursing in Belgium

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1 16 Intent to leave nursing in Belgium Sabine Stordeur, Philippe Kiss, Rini Verpraet, Marc De Meester, Lut Braeckman and William D hoore Introduction In Belgium, there are shortages of personnel throughout the service occupations. Nursing is particularly affected, with health care institutions experiencing difficulties recruiting and retaining staff (Afis and Femarbel, in Béchet, 2003). Nursing training attractiveness slightly decreases among 18 year old students (Leroy et al., 2003) and those already employed as nurses are dissatisfied with their working conditions (De Troyer, 2000). This has encouraged them to reduce their working hours, to seek new jobs where the conditions of employment are better or to leave nursing altogether. Moreover, nurses are getting older, resulting in numerous departures for retirement in the next decade. Nurses and nurses aids is the largest group of health professionals. However, workforce planning has not been adequately addressed by the government. According to the Public Health Ministry (2001): Today, it is impossible to estimate nursing personnel working in health care sector as well as to plan the evolution of this sector needs. The last available data are seven year old. In all types of health care institutions, the debate about appropriate nursing staffing levels is ongoing. In hospitals there was also a recent debate concerning the adequate ratio between qualified nurses and nursing aids. In addition, changes in medical training have implications for the number of nurses recruited and the nature of their training. The restriction of medical students admission by a numerus clausus has resulted in a lack of specialized doctors, with the need to adapt nursing education (standardization of diplomas, role differentiation between certificate and registered nurses, length of training, links between trainings, degree of specialization, clinical specialists). However, there is no consensus on the best way of introducing these changes in nursing. Finally, working conditions have generated a great deal of dissatisfaction. The tension caused by heavy workload, low professional status, relationships between the different health care disciplines, unpredictable work schedules, occupational health risks and the emotional demands of nursing affect nurses motivation. In Belgium, these problems are present since 1980, but are now further compounded by social changes such as the aging population, the reorganization of health care institutions and the way they are financed. In 2000, there were 174,010 people working in the nursing profession in Belgium. About 60% of them were working in hospitals and 25% in long-term 125

2 care institutions. The remaining 15% were employed in home care services. The main professional categories were registered nurses and certificate nurses, representing 74% of the active work force in nursing. Nursing aids accounted for the remaining 26%. The shortage of nurses and especially insufficient staffing are crucial issues for Belgian politicians and health services managers (Béchet, 2003). Whereas all settings reported problems in recruiting qualified nurses, this problem is more severe in old peoples homes than in hospitals, because in this sector, 250 nursing posts are vacant for the whole country (Béchet, 2003). Nevertheless, hospitals have also many difficulties to employ highly qualified registered nurses with adequate specialisations, and they are obliged to recruit less qualified personnel. The problem is exacerbated by the high numbers of part-time nurses (45% in hospitals), the low rate of activity in the profession (only 69% of registered nurses work in health system), the pregnancy and maternity leave (12 months) and the breastfeeding period (3 months), and government initiatives to progressively reduce working hours prior to retirement (1 day off per month from 45 year old, 2 days off per month from 50 year old and 3 days off per month from 55 year old). This is expected to increase substantially in the coming years. Despite attempts to increase and diversify the supply in nursing education, interest in nursing has declined among young people (attractiveness of nursing training decreased by 1.5% these last 5 years). Not only is the number of applicants decreasing, but also their quality (less than 30% of nursing students obtained their diploma after 3 years of training) (Leroy et al., 2003). International migration is a special issue in Belgian health care because in Belgium, we do not have closing classes or numerus clausus regulation. This situation attracts many French students rejected according to numerus clausus regulation or students reluctant to undertake the exams to enter in French nursing schools. These students come to Belgium and work thereafter in France. Thus, 31% of students in Belgium come from other countries (20% graduate nurses 50% certificate nurses), and 68% are French students. Retaining nurses in healthcare settings requires a detailed investigation of the reasons and the circumstances for premature departure from the nursing profession. The NEXT-Study is the first study investigating this issue in Belgium, where it is being conducted by two institutions: Université catholique de Louvain (Brussels) and Universiteit Gent. Methods Recruitment of institutions For selecting the Belgian participating institutions, we used a stratified sample of hospitals, home care services and long-term care, based on the following criteria: (1) each of the three regions had to be represented (Brussels, Wallonia and Intent to leave nursing in Belgium

3 Flanders); (2) status (we selected a balance of private and public institutions); (3) former restructuring (grouped and non-grouped institutions). Forty-eight hospitals, home care services and nursing homes were randomly selected and asked to participate. Of those, 37 were finally included in the study. A requirement for participation with written confirmation of active participation was signed both by administration and staff representatives of the institutions (executive boards and works committees). In all participating institutions, all nursing staff were included. One institution withdrew from the study, because a lack of participation affected data collection. The selected study base did not completely represent the Belgian distribution of nursing staff in the three types of institutions investigated in NEXT: nursing staff in hospitals were well represented (54% in this sample vs. about 61% in Belgium), staff from nursing homes is underrepresented (7% vs. 14%) whereas (Flemish) home care institutions are over-represented (39% vs. 25%). The main reason for this deviation is that the Flemish region has a very well organized home care sector. By contacting the principal coordinator, who agreed to collaborate to NEXT study, we obtained the collaboration of the 5 main centres in Flanders which employs more or less 2,000 nurses. Please note that 67% of Belgian nurses who work in home care sector, work in the Flemish Region. Consequently, the over representation of Flemish home care nurses in our sample adequately represents the nursing workforce in Flanders. Nurses working in nursing homes are not well represented; this is mainly due to the small size of institutions, needing to include more institutions, and to the refusal of some directors of contacted nursing homes to participate. Participation In Belgium, 4,257 of those approached (61.3%) returned the Q0 (Table 1). The response rate in the different institutions ranged from 20.7% to 100% (mean and median 65%). Participation was highest in home care organizations (except one having two languages: French and German, and many internal problems) and lowest in the two university hospitals. 16 Intent to leave nursing in Belgium 127

4 Table 1. Overview over participating institutions and staff in the Belgian basic assessment. institution number of n staff n staff response range of institutions approached responded rate response rates university hospital 2 1, % 34.5% 53.8% hospital > 400 beds 2 1, % 34.1% 56.9% hospital < 400 beds 12 1, % 43.0% 67.9% nursing home % 37.5% 100% home care 10 2,075 1, % 20.7% 90.6% all 37 6,947 4, % 34.1% 100% Data entry and statistical analysis Data entry was done by optical recording. Plausibility tests checked for outliers and implausible data. Errors (e.g. full time contract having more than 38 hours a week) were treated as missing values. The following data analysis has been conducted with SPSS Results Nursing staff working in hospitals included 54% of all participants, those working in old peoples homes and in home care, 7% and 39% respectively (Table 2). According to the type of institution, there was no statistical differences between the mean age of female nursing staff and that of their male colleagues (two-factorial ANOVA effect for age (F(2/3,927)=.89, p>.05, interaction for institution and gender (F(2/3,927)=.04, p>.05)). A one-way ANOVA also indicated that mean ages of nursing staff were comparable in the three settings Intent to leave nursing in Belgium

5 Table 2. Participants in Belgium by type of institution, gender and age. type of institution n % mean age stdev. age hospital female 1, male all 2, old peoples homes female male all home care female 1, male all 1, all female 3, male all all 4, missing 32 total 4,257 Intent to leave Of the 3,973 respondents who answered to this question, 4% thought of giving up nursing completely ( intent to leave, ITL) several times per week or daily, an additional 5.3% considered this monthly (Table 3). However, ITL varied with respect to a) gender, b) age, c) type of institution, d) qualification, e) seniority, f) health and work ability. Each of these aspects will be fully investigated in relation to intent to leave the profession. Where appropriate, the sample was dichotomised with respect to the intensity of thinking about leaving the profession. Those thinking of this several times per month and more were compared to those considering it less often or not at all. Table 3. Response distribution to the question: How often during the course of the past year have you thought about giving up nursing completely? answering category frequency percent 2, , all 3, a) Gender. Whereas 8.8% of female nurses frequently thought about leaving nursing, 14.6% of male nurses thought about giving up nursing completely 16 Intent to leave nursing in Belgium 129

6 (χ 2 =18.6, 2 df, p<.0001). This result was particularly salient in hospitals where 14.7% of men thought frequently about leaving nursing. Nevertheless, in the two other settings, men were under represented. The gender effect is mainly due to the age groups from 30 to 40 years, where intent to leave the profession was very high in men group (19%). Among women, the intent to leave was most prevalent in the age group from 26 to 30 years (9.8%). Intent to leave also depended on nursing qualification: it was higher among registered nurses (with or without specialization) than among nursing aids (with or without health care training) (χ 2 =38.4, 6 df, p<.0001). Figure 1. Response by gender: How often during the course of the past year have you thought about giving up nursing completely?. (n=3,952, n women =3,609, n men =343) 100% 80% 60% 40% 20% 0% women men b) Age. Age was clearly associated with intent to leave in a curvilinear way (Figure 2). Younger nurses showed a higher intent to leave with a maximum in the 30-to-34 years age category. A large part of nursing staff 50 years of age and older did not think about leaving. In Belgium, recent governmental initiatives were taken to keep older nurses at work: employees who are at least 45-years old can choose either to benefit 1 to 3 days off per month without loss of salary, or to maintain a full-time with salary increment. These measures appear to have been successful Intent to leave nursing in Belgium

7 Figure 2. Response by age: How often during the course of the past year have you thought about giving up nursing completely?. (n total =3,948, n -24 =382, n 25+ =614, n 30+ =559, n 35+ =803, n 40+ =699, n 45+ =488, n 50+ =265, n 55+ =138) 100% 80% 60% 40% 20% 0% age groups c) Type of institution. Nursing staff in home care considered leaving nursing less often (5.5% considering this at least several times per month) than those working in nursing homes (11.3%) and hospitals (12.7%). A chi-square test confirmed the significance of this result (χ 2 =78.8, 4 df, p<.0001). In single institutions, the rate of nursing staff considering leaving the profession every month or more often ranged from 0% to 22.2% (median 9.4%). In two institutions, none of the participants considered leaving the profession every month or more often. They were one old peoples home and one home care organisation. In Brussels, the rate was not as high as expected (according to additional pulling factors increasing the difficulties of employees, such as difficulties to acquire affordable housing, long and difficult journeys, insufficient opportunities for child care, ) but varied substantially between institutions from 4% to 18.2%. This implies that there are attractive institutions which probably develop effective strategies to retain nurses. Figure 3. Frequency of intent to leave the nursing profession by type of institution. (n total =3,873, n hospital =2,172, n nursing home =176, n home care =1,525) 100% 80% 60% 40% 20% 0% hospital nursing home home care 16 Intent to leave nursing in Belgium 131

8 d) Qualification level. Registered nurses (with and without specializations) (Figure 4) expressed a higher ITL than the other team members. This result can be explained by the special opportunities offered to nurses having a specialisation, but also by their higher level of expectations regarding the working conditions (opportunities of professional development, recognition of their qualification, wages,...). If the employer does not meet their expectations, these are likely to seek a more satisfying job. Figure 4. Level of qualification by intent to leave. (n total =3,851, n nurse+spec =788, n reg.nurse =2,651, n aides =372, n no training =40) registered nurse and specialisation registered nurse nursing aides no health care training 0% 20% 40% 60% 80% 100% e) Seniority. Although most staff in the sample had been employed in nursing for a long time (mean: 14.9 years, no differences between types of institution), nurses did not remain in the same institution throughout their career (mean institutional seniority: 4.4 years; median: 5 years). This propensity to change from one institution to another can be explained by two factors: the general basic training which helps nurses to be adaptable to different work environments and the perpetual need to fill vacancies in the health care system. This mobility also explains the ongoing need for institutions to engage new nurses and to train them, increasing the perceptions of nursing shortage. Figure 5 indicates that ITL the nursing profession was already expressed at the beginning of the career. This was the case both for women and men Intent to leave nursing in Belgium

9 Figure 5. Occupational seniority in relation to ITL. (n total= 3,944, n 1year =157, n 2years,=185, n 3years =171, n 4years =165, n 5years =171, n 6-10years =553, n 11-15years =726, n 16+years =1,294, n 26+years =522) 1 year to to to years + 0% 20% 40% 60% 80% 100% Intent to leave the nursing profession was not explained by years in service, even if after 5 years in the same institution, nurses think less frequently about leaving nursing. Figure 6. Institutional seniority in relation to ITL. (n total =4,053, n < 6month =153, n 6-12month =183, n 1-2years =368, n 3-5years =578, n > 5 years =2,771) < 6 months 6-12 months 1-2 years 3-5 years > 5 years 0% 20% 40% 60% 80% 100% f) Health and work ability. Health and work ability were found to be predictors of intent to leave health care. For men and women, low self rated health and low work ability were associated with higher intent to leave the nursing profession (Figure 7). 16 Intent to leave nursing in Belgium 133

10 Figure 7. Work Ability Score (WAI) in relation to intent to leave nursing. (n total =3,625, n poor =81, n moderate =731, n good =1,932, n excellent =881) 100% 80% 60% 40% 20% 0% poor moderate good excellent work ability score g) Exhaustion. Burnout was also clearly associated with ITL (Figure 8), whatever the individual s nursing qualification. Note that 22.4% of women expressed high levels of burnout (score>50) in comparison with 13.1% of men (χ 2 =19.04; 3 df; p<.001). Figure 8. Burnout in relation to intent to leave nursing. (n total =3,812, n score<25% =1,483, n score 26-50% =1,458, n score 51-75% =790, n highest score =81) 100% 80% 60% 40% 20% 0% lowest quartile % % highest quartile burn out score Discussion There appears to be a potential problem of nursing shortage in Belgium because nurses, despite strong professional commitment frequently express intent to leave. Problems are different like are the strategies to prevent their respective effects. On the one hand, preliminary results indicate that solutions have to be found to prevent withdrawal of young and highly qualified nurses, but also to retain male nurses in the nursing profession (balance between the two genders is important for several reasons: status of professional vs. the traditional image of the vocation, heavy workload, ). On the other hand, particular attention should be paid to older nurses, who have developed clinical expertise, and how their Intent to leave nursing in Belgium

11 organisation operates. Proposing new solutions to their age-specific problems are particularly important in the context of nursing shortage. Another part of the investigation which could add important contribution to the identification of associations between intent to leave and some significant exposure is to consider organisational factors. Preliminary multiple linear regression analyses revealed that if mental and physical health indicators were associated with intent to leave (standardized regression coefficients=.17, -.10,.05 respectively; p<.01), organizational attributes were even more associated with intent to leave, including affective commitment towards profession and institution, and job satisfaction (standardized regression coefficients=-.22, -.17, -.11 respectively; p<.0001). More sophisticated statistical modelling should be performed to investigate relationships between these factors. Beside paying more attention to nurses welfare, more could be done to adapt organisations to nurses expectations, since a body of knowledge shows that commitment is closely linked to satisfaction and both are a response to leadership, job control, nurses autonomy, and organisational climate (Stordeur, 2001). References Béchet G (2003) On recherche des blouses blanches. Le Soir, February 11 th. De Troyer M (2000) The hospital sector in Europe Introductory report. TUTB- SALTSA Conference 2000:25-27, Brussels. Leroy X, Hubin M, Stordeur S, Draelants H & De Backer B (2003) Manpower Planning Offre et demande de travail dans le champ de la santé et de l aide sociale en Communauté française et en Communauté germanophone de Belgique ( ). Tome 2. Bruxelles: Université catholique de Louvain. Stordeur S (2001) Leadership transformationnel des infirmières en chef et contexte de travail: impact sur l équipe infirmière et la satisfaction des patients. Thèse de doctorat en Santé Publique, Université catholique de Louvain. Bruxelles: UCL. 16 Intent to leave nursing in Belgium 135